Immunotherapy plus chemotherapy in advanced biliary tract cancers: pros and cons

INTRODUCTION: Biliary tract cancers (BTC) are highly immunosuppressive 'cold' tumors with limited treatment options. In unresectable or advanced-stage disease, the combination of immune checkpoint inhibition with chemotherapy resulted in a modest survival benefit over chemotherapy. AREAS COVERED: In this review, current obstacles and strategies to improve the benefit of immunotherapy are highlighted. This includes challenges in optimizing patient selection, understanding the tumor microenvironment and interactions with the gut microbiome, and improving combination treatment strategies, whether with targeted agents, locoregional therapies, or other evolving immune therapies. For this review, we performed a PubMed database search and summarized all relevant clinical studies utilizing ICIs in biliary tract cancers from 2019 to the present. EXPERT OPINION: Checkpoint inhibition plus chemotherapy is established as a new standard of care for patients with advanced BTC, with a clinically meaningful subset of patients now achieving durable long-term survival that was previously rare in this disease. The next challenge is to broaden that benefit through biomarker-driven patient selection, use of immunotherapy in earlier stages of disease, and through rational combination strategies. Importantly, these approaches should be grounded in a better understanding of tumor biology as well as the host immune microenvironment.